Grabb’s Encyclopedia of Flaps Head and Neck

mit dem freien Unterarmlappen. Der Chir 1981;52:635.
4. Muehlbauer W, Hemdl E, Stock W. The forearm flap. Plast Reconstr Surg 1982;70:336.
5. Stock W, Muehlbauer W, Biemer E. Der neurovaskulaere Unterarm-Insel-Lappen. Z Plast Chir
1981;5:158.
6. Biemer E, Stock W. Total thumb reconstruction: A one-stage reconstruction using an osteocutaneous
forearm flap. Br J Plast Surg 1983;35:52.
7. Soutar DS, Scheker LR, Tanner NSB, McGregor IA. The radial forearm flap: A versatile method for
intraoral reconstruction. Br Plast Surg 1983; 36:1.

Chapter 203
Facial Artery Musculomucosal (Famm) Flap
H. O. B. TAYLOR
J. J. PRIBAZ
EDITORIAL COMMENT
This is an excellent arterialized flap for reconstructions of the lower lip, particularly those including the
vermilion. The donor site is usually quite acceptable, and there is no functional deficit. One should
remember that wet mucosa transferred to the outside tends to dry and needs constant lubrication.
Refinements of previously used buccal mucosal flaps have led to the facial artery musculomucosal (FAMM) flap,
which, through its axial pattern blood supply, oblique orientation, and high length-to-width ratio, provides a robust
donor for the reconstruction of mucosal defects throughout the mouth and nose, with minimal donor-site
morbidity With attention to detail, and inclusion of the facial artery along the full length of the flap, a long and
narrow flap may be harvested in either a superiorly or inferiorly based manner, with few donor-site or flap
complications.
INDICATIONS
Oral and perioral reconstruction requires the transfer of surrogate specialized tissues to reconstruct form
and function. In the past, the buccal mucosa was utilized as a random musculomucosal flap (1, 2). The
subsequent FAMM flap has been used in the reconstruction of a broad array of nasal and oral defects,
including those in the palate, alveolus, nasal lining, maxillary antrum, tonsillar fossa, and floor of the mouth
(3). It is particularly useful for reconstructing lip defects that may be too large to reconstruct with transfer of
adjacent vermilion (4). The color, texture, and moisture of the mucosa carried by the FAMM flap combine to
make it an excellent option for wet vermilion reconstruction. Although a number of other options exist for lip
reconstruction, including mucosal grafts, labia minora grafts, two-stage flaps such as the tongue flap, cross-
lip flap, bilateral island vermilion flaps, and free-tissue transfer (5), the FAMM flap provides a hardy source
of axially perfused musculomucosal tissue in a single-stage procedure.
ANATOMY
The FAMM flap is an axial buccal flap based on the facial artery, a branch of the external carotid system, which
curves beneath the lower border of the mandible, at the anterior aspect of the masseter muscle. Passing in a
serpentine fashion, upward toward the commissure, the facial artery lies deep to the risorius and zygomaticus
major muscles, but superficial to the deepest perioral muscles, the buccinator, levator anguli oris, and the deep
lamina of the orbicularis (Fig. 203.1A and B). Here it gives rise to multiple perforators of the cheek and continues
superiorly toward the medial canthus of the ipsilateral eye as the angular artery. Anastomoses exist along its
course with the buccal and infraorbital arteries. There is no named vein that drains this region, but a rich network
to the anterior facial vein and posterior pterygoid plexus and internal maxillary vein provides a robust outflow.
The position of the facial artery superficial to the buccinator requires that the FAMM flap include layers of
mucosa, submucosa, and buccinator muscle in order to capture the vessel.

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FLAP DESIGN AND DIMENSIONS
If one is careful to include the facial artery along the full length of the flap, it is possible to design a long (7 to 8
cm) and narrow axially perfused flap. It may be based superiorly (Fig. 203.2A), or inferiorly (Fig. 203.2B). The
flap includes layers of mucosa, submucosa, a strip of buccinator muscle, and the facial artery above it. Inclusion
of the required layers deep to the facial artery makes the flap approximately 8 to 10 mm in thickness. Using a
Doppler ultrasound, the surgeon marks the course of the facial artery intraorally. No effort is made to include
identifiable venous drainage, particularly in the superiorly based flaps, but despite this, it is rare for these flaps to
become congested.
OPERATIVE TECHNIQUE
For the superiorly based flap, after Doppler ultrasound is used for the facial artery, the first incision is made
anteroinferiorly
through the mucosa, submucosa, and buccinator, to identify the axial vessel. Before proceeding, the facial artery
is ligated and divided. The edges of the rest of the flap are incised and elevated from inferior to superior,
including the three soft-tissue layers (mucosa, submucosa, buccinator) and the axial facial artery along the full
length of the flap. For inferiorly based flaps, a mirror-image procedure is performed. The first incision is made
anterosuperiorly, to identify and divide the facial artery in the upper lip. The flap is then elevated toward its
inferior base. In this circumstance, the facial vein may be seen in the lateral inferior dissection.
FIGURE 203.1 A,B: The anatomy of the facial artery. A branch of the external carotid system, the facial artery
hooks around the mandible just anterior to the border of the masseter. It courses toward the commissure and
then toward the medial canthus, as the angular artery. With respect to the perioral muscles, it lies deep to the
zygomaticus minor (B), zygomaticus major (C), risorius (D), depressor anguli oris (E), and depressor labia
inferiors (F), and the superficial lamina of the orbicularis oris (G). It lies superficial to the buccinator, the deep
lamina of the orbicularis oris (G), and the levator anguli oris (A).

FIGURE 203.2 A: The superiorly based FAMM flap can reach the hard plate (1), the upper lip and alveolus (2),
the maxillary antrum, nose, and even the inferior orbit (3). B: The inferiorly based FAMM flap can reach the lower
lip and floor of mouth (1), the soft palate and tonsillar fossa (2), and the hard palate and alveolus (3).
CLINICAL RESULTS
We have used the FAMM flap to reconstruct a broad array of defects, including those secondary to
inherited anomalies (e.g., lip vermilion in hemifacial microsomia, cleft palate), oncologic resections, vascular
anomalies, and trauma. The tissue and color match provide a good substitute for native tissue, and the
fullness of the flap is useful for reconstructing the appropriate lip contour, particularly for central and full-
thickness defects. We have used this flap for vermilion reconstruction, in conjunction with free-tissue
transfer reconstructions of larger perioral composite defects. Donor-site morbidity is low, with few
complications in wound healing and minimal interference in facial animation.
SUMMARY
The FAMM flap is a flexible and safe flap that provides excellent tissue match for lip and vermilion
reconstruction, as well as for multiple other defects around the mouth and nose.
References
1. Rayner CR, Arscott GD. A new method of resurfacing the lip. Br J Plast Surg 1987;40:454.
2. Bozola AR, Gasques JA, Carriquiry CE, et al. The buccinator musculomucosal flap: anatomic study and
clinical application. Plast Reconstr Surg 1989;84:250.
3. Pribaz J, Stephens W, Crespo L, et al. A new intra-oral flap: facial artery musculomucosal (FAMM) flap.
Plast Reconstr Surg 1992;90:421.

4. Pribaz JJ, Meara JG, Wright S, et al. Lip and vermilion reconstruction with the facial artery
musculomucosal flap. Plast Reconstr Surg 2000;105: 864.
5. Langstein HN, Robb GL. Lip and peri-oral reconstruction. Clin Plast Surg 2005;32:431.

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Chapter 204
Radial Forearm Free Osteocutaneous Flaps for Intraoral
Reconstruction
J. B. BOYD
EDITORIAL COMMENT
This is an excellent description of the harvesting of bone with the radial forearm flap. The bone is quite
useful for short defects of up to 10 cm in a straight line. The procedure is not intended for use around the
mentum, where a curving bone is needed. Postoperatively, the forearm requires splinting for at least
6weeks to decrease the incidence of radial bone fractures.
The radial forearm osteocutaneous flap, basically a fasciocutaneous flap based on the radial artery, is thin,
supple, and easy to elevate. It has large vessels, a long pedicle, and a capacity to be sensate or to carry a bone
supply (1, 2, 3, 4, 5). It also has the advantage of allowing simultaneous dissection in two-team head and neck
surgery. This flap is especially useful for low-volume, short (2-10 cm) mandibular defects.
INDICATIONS
The capacity of the forearm flap to carry two separate skin paddles allows it to reconstruct full-thickness
defects (6) with an ease not matched by the fibula or iliac crest (7). It also provides mucosal replacement
second to none. The skin flap is thin, supple, and, with reinnervation, capable of sensation approaching
that in the normal mouth, which enhances oral continence and may improve speech, mastication, and
swallowing (4).
The segmental supply of the radial bone by the artery allows it to be osteotomized once or twice for
accurate contouring in the symphysial and parasymphysial regions. A lateral segment of mandible may be
handled as a “straight shot,” using the radial bone as a biocompatible reconstruction plate.
ANATOMY
The bone carried by this flap is approximately one third of the cross-sectional area of the distal anterolateral
radius (Fig. 204.1). Although small, the bone is quite strong and will accept osseointegrated implants for dental
rehabilitation (8).
The skin of the anterior forearm receives a significant blood supply from the radial artery via septocutaneous
vessels passing along the septum between the brachioradialis and the flexor carpi radialis muscles (the lateral
intermuscular septum). These perforators are plentiful in the distal third of the forearm, but proximally, where
tendons give way to muscle bellies, they become rather sparse. Nevertheless, it is probably safe to raise a
septum-based skin flap anywhere along the course of the radial artery. In this way, two skin islands may be
raised, one proximal and one distal, to facilitate reconstruction of the through-and-through defect.
After emerging from the septum, the vessels branch laterally and medially, piercing the deep fascia and quickly
passing to the subdermal plexus to supply the skin. Contrary to previous teachings, these vessels do not travel
on the surface of the deep fascia for any significant distance; as a result, little of the deep fascia needs to be

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harvested with the flap.
FIGURE 204.1 A: Section of distal forearm showing disposition of radial artery with respect to vascular septum,
flexor pollicis longus, and the osteotomy. One third of the radial cross section is taken with an osteotomy, which
passes posteriorly and laterally from the midline of its anterior surface. The skin paddle is situated over the
dorsoradial aspect of the wrist to include the cephalic vein. This improves vessel access in the neck but is
admittedly detrimental to the postoperative cosmetic appearance at the wrist. B: Muscular attachments to the left
anterior radius and ulna with respect to the radial bone graft. The graft extends between the insertions of the
pronator teres and brachioradialis (some of which are included for extra length). Note that the osteotomy is
“boat-shaped” to avoid cross cutting at the corners and excessive weakening.
The brachial artery bifurcates into radial and ulnar arteries a few centimeters distal to the antecubital fossa. The
radial artery and its venae comitantes are invested by the fascia of the lateral intermuscular septum. The artery
passes distally along the radial side of the pronator teres, initially lying between the biceps tendon and the
bicipital aponeurosis. It then crosses anterior to the pronator teres, just proximal to that muscle's insertion into its
tubercle on the lateral surface of the radius. On entering the distal third of the forearm, it first overlies the flexor
pollicis longus and finally the pronator quadratus. These two muscles intimately clothe the flat anterior surface of
the distal radius (Fig. 204.1). Muscular branches from the radial artery give periosteal twigs to the underlying
bone and are the basis for the osseous portion of the flap.
Classically, there are three major subcutaneous veins in the anterior forearm: the cephalic, the median, and the
basilic. There are significant variations on this basic pattern. Perforating veins connect the superficial veins to
the deep system at various points. Of most interest here is the communication at the level of the brachial artery
bifurcation, which may be single or multiple and may be from any of the superficial veins (commonly the median).
Either the venae comitantes or the large subcutaneous veins of the forearm are capable of draining the
osteocutaneous forearm flap. The superficial veins are often preferred because of their greater diameter and
their independence from

the arterial pedicle. Care should be taken, however, to ensure that the superficial veins have not been canalized
previously and undergone partial or complete thrombosis.
The medial antebrachial cutaneous nerve (C8, T1) enters the forearm in the company of the basilic vein. It soon
gives off a number of large anterior branches that pass down the radial side of the basilic vein and supply the
ulnar half of the anterior forearm as far as the wrist. An ulnar branch supplies the ulnar border of the forearm.
The lateral antebrachial cutaneous nerve (C5, C6) is the forearm continuation of the musculocutaneous nerve. It
enters the forearm on the ulnar side of the cephalic vein and, via multiple branches, supplies the radial half of the
forearm as far as the wrist as well as the dorsoradial aspect of the forearm.
FLAP DESIGN AND DIMENSIONS
It is useful to mark the radial artery and the larger subcutaneous veins on the skin surface. The skin flap is
usually positioned over the anterior or anterolateral aspect of the distal wrist. Here the subcutaneous tissue is
thinnest, the skin is reasonably hairless, and the pedicle length is maximized. The relationship of the skin flap to
the bone graft should be assessed carefully in view of the expected recipient defect. The bone graft will extend
proximally for up to 12 cm from a point 2 cm proximal to the tip of the styloid process (see Fig. 204.1). Usually,
the recipient defect requires the skin paddle to lie over the midpoint of the bone, but this is not always the case. It
is advantageous to position the flap anterolaterally in such a way that part of it overlies the cephalic vein. This
vessel can be used for venous drainage. In hirsute patients, the flap may be positioned purely on the anterior
aspect of the distal wrist where the skin is less hairy for a superior cosmetic result. Unfortunately, the median
vein is often quite small in the distal wrist. If an innervated flap is required, it should be noted that the watershed
between the neurosomes of the lateral and medial antebrachial cutaneous nerves lies down the midline of the
anterior forearm. Those positioned centrally, and straddling two neurosomes, require both superficial nerves (4).
The flap may be of almost any dimensions as long as a significant portion of it overlies the vascular septum.
Practically, the whole anterior forearm skin may be taken safely, but this is rarely required. Limits extend from the
antecubital fossa to the transverse wrist crease and from the ulnar border of the forearm to the posterolateral
aspect of the radial border. Raising a flap of such dimensions would require the entire vascular septum to be
preserved. The “base” of any radial forearm skin flap is that portion in direct contact with the vascular septum.
Like any flap, if the base is small, the surviving length is accordingly reduced.
When small skin islands are required (less than 6 × 4 cm), it is sometimes possible to perform primary closure at
the donor site (9). Such a flap is positioned transversely with one edge overlying the radial artery. Closure is
effected by means of a long, ulnar-based rotation-advancement of the entire proximal forearm skin. The proximal
defect is closed as a V to Y. Wrist flexion facilitates closure.
OPERATIVE TECHNIQUE
A preoperative Allen's test should always be done, but its meaning is open to question. Only in a severe
arteriopathy would grafting of the radial artery be necessary. Many cases have been performed in the presence
of an unfavorable Allen's test, with no adverse sequelae. One possible cause for an ischemic hand following this
surgery is the inadvertent ligation or division of a superficial ulnar artery, which can lie in the superficial tissues
along the medial border of the flap. With the tourniquet up, this may take the appearance of a large vein. Such a
vessel is at most risk with skin paddles that intrude onto the ulnar border of the wrist.
A tourniquet is placed around the upper arm. The arm is incompletely exsanguinated using an Esmarch or an
Ace bandage before dissection commences.
The skin flap is incised around its periphery, and dissection is carried down to the underlying muscle fascia.
Care is taken at the proximal margin of the flap to identify and preserve the cephalic vein or any other superficial
veins. An incision is made from the proximal edge of the flap incision straight up the forearm toward the

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antecubital fossa. Dissection is carried through the subcutaneous tissue, and the selected venous system is
traced proximally. If an innervated flap is desired, all the subcutaneous nerves entering the flap should be
preserved in a sheath of fascia; they tend to lie just superficial to the deep fascia. Precise identification of the
nerves is best made in the proximal forearm, where they are large and located next to the cephalic and basilic
veins. These nerves and their relevant branches then can be traced distally into the proximal margin of the flap.
The ulnar side of the flap then is elevated at a level just superior to the deep fascia, working toward the
intermuscular septum between the brachioradialis and the flexor carpi radialis. Approximately 1 cm on the ulnar
side of this septum, the deep fascia is incised, and dissection then passes under it. Preservation of the deep
fascia in this way facilitates skin grafting of the donor site. Dissection proceeds over the surface of the flexor
carpi radialis tendon, leaving paratenon behind. It then extends around the radial edge of the tendon into the
space beneath. Usually, the superficial fibers of the flexor digitorum superficialis muscle are now visible.
Dissection around the radial side of this muscle allows it to be retracted in an ulnar direction. When this is done,
the fibers of the flexor pollicis longus are seen arising from the flat anterior surface of the distal radius and the
adjacent interosseous membrane. This completes dissection on the ulnar side.
The radial dissection is similar to that on the ulnar side. It passes immediately superficial to the deep fascia until
a point is reached 1 cm lateral to the intermuscular septum, where the deep fascia is divided and dissection then
proceeds at this deeper level. The brachioradialis tendon is seen, and the dissection hugs this tendon in the
same way as the ulnar dissection hugged that of the flexor carpi radialis. Paratenon is preserved. Once around
the ulnar border of the brachioradialis tendon, the plane of dissection remains close to its undersurface. A space
filled with loose adventitial tissue is soon entered. Blunt dissection in this space exposes the dorsoradial bare
area of the radius.
Distally, the radial artery and its venae comitantes are easily identified; these are ligated and divided. The
brachioradialis tendon is elevated somewhat from its attachment to the distal radius; however, care is taken to
preserve its distal attachment. This maneuver allows a little more radius to be included in the osteocutaneous
flap because the attachment of the brachioradialis defines the distal limit of the bone graft. The cephalic vein is
ligated and divided distally, as are other small veins in the region.
It should be noted that the superficial branch of the radial nerve passes through the deep portion of the flap and
is visible during the radial dissection. This nerve is not to be used for innervation purposes. The nerve can be
easily dissected from the undersurface of the flap, and it is virtually never necessary to sacrifice it.
The proximal portion of the intermuscular septum between the brachioradialis and the flexor carpi radialis is
entered and communicated with the more distal dissection. The radial artery and its venae comitantes are
immediately visible between these muscles. Proximal to the skin island, it is not necessary to maintain any skin
perforators, septal or otherwise.
The vascular leash is dissected free of surrounding tissues. It can be taken all the way up to the origin of the
radial artery from the brachial artery, just distal to the antecubital fossa. The superficial venous system
communicates with the deep system of veins just distal to this point. This communication may be preserved as
part of a combined venous pedicle (10). Both cephalic vein and superficial nerves may be dissected into the
upper arm to obtain greater length.
Now attention is focused on perhaps the trickiest part of the operation: the osteotomy (Fig. 204.2). At this point,
the radius is totally obscured from view: its anterior surface is clothed by the muscle fibers of the flexor pollicis
longus. The lateral border of the radius is palpated easily, but the medial border is not, due to the tightness of
the interosseous membrane. Passing a fine hemostat through the flexor pollicis longus muscle is a way of
establishing where the bone ends and where the interosseous membrane begins. In this way, it is possible to

visualize mentally the radius as it lies underneath the flexor pollicis longus muscle. A line is drawn longitudinally
down the anterior surface of the flexor pollicis longus muscle at a point corresponding to the exact midline of the
flat anterior face of the radius. The osteotomy will pass from here, dorsally and laterally, toward the bare area
(Fig. 204.1). If the osteotomy were to pass perpendicularly through the radius, then half the cortex would be
harvested. By angling the osteotomy laterally toward the bare area, however, it is ensured that only one third of
the circumference of the radius is taken as a graft (Fig. 204.2).
The muscle fibers of the flexor pollicis longus muscle then are divided. The incision passes all the way down to
bone. It extends from the distal radius proximally for about 12 to 14 cm. The periosteum is elevated for a short
distance on either side of the incision so that the radius can be visualized along the line of the proposed
osteotomy. The proximal extension of the osteotomy eventually will exit the radius laterally. This point will be
situated either at or near the pronator tubercle. Insertion of the pronator teres has been widely accepted as
defining the most proximal permissible extent of the osteotomy, just as the insertion of the brachioradialis tendon
has been said to set the limit for the distal extent.
FIGURE 204.2 A square-shaped osteotomy has been completed and the flap isolated on its pedicle. This radius
went on to undergo fracture! Boat-shaped osteotomies are probably safer.
By now, the bone has been prepared for osteotomy medially, laterally, and proximally. It remains only to
communicate the flexor pollicis longus splitting incision distally with the bare area of the radius immediately
proximal to the remaining insertion of the brachioradialis muscle. There is nothing of vital importance that can be
divided in this area, but some large branches of the radial artery may need to be tied off.
It is hoped that the dissection will take less than 2 hours of tourniquet time. The tourniquet is released, and
hemostasis is established by the usual means. The osteotomy is best performed using a fairly powerful
reciprocating saw with a narrow blade not exceeding 1.5 cm in width; this is essential if the saw is to be guided in
its course through the bone. With assistants retracting the vital structures and providing irrigation, the
reciprocating saw enters the distal radius under the tendon of the brachioradialis muscle at approximately 45
degrees to the bone surface and angled proximally. The osteotomy passes proximally until it is in the vicinity of
the pronator teres insertion, and then it is angled out through the lateral cortex. Again, it follows the
predetermined cut that has already been made in the soft tissues. Because one continuous osteotomy has been
made (Fig. 204.1), the graft is boat- or keel-shaped and there is no cross cutting (11, 12) (Fig. 204.2).
The bone is observed to bleed from its cut surface, and the flap is observed to have a good capillary return. After
15 min of perfusion, the pedicle is divided and the flap removed to the recipient site.
Perfusion of the hand by the ulnar artery should be assessed at this stage. With proper preoperative
assessment, there should be no surprises. Nevertheless, the surgon should be prepared to graft the radial artery
if faced with obvious arterial insufficiency; in practice, this is extremely rare.

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To facilitate wound closure, the palmaris longus tendon usually is removed and discarded. The proximal portion
of the wound is closed directly. Although the paratenons of the flexor carpi radialis and the brachioradialis have
been preserved and probably would accept a skin graft, it is often better to bury the tendons among the fibers of
the flexor digitorum superficialis muscle. By whatever means, a flat, well-vascularized bed is produced to receive
an unmeshed skin graft held in place by a meticulous tie-over dressing. The graft remains unmeshed to maximize
the bridging phenomenon, which may help to avoid tendon exposure. The immediate result of harvesting a radial
bone graft is a diminution in the breaking strength of the radius by 76% (11). The risk of fracture following
relatively minor trauma mandates cautious rehabilitation.
The wrist, including the thumb, then is immobilized in a palmar splint, which is generally not removed for 7 days.
When it is removed, the patient is fitted with an above-elbow cast (preferably fiberglass) or splint with a window,
if necessary, to continue dressings at the skin-graft recipient site. The cast should hold the elbow at right angles
and the wrist in moderate extension. The thumb can be free at this stage. The patient wears the above-elbow
cast for a period of 2 months, and then the upper portion is removed, converting it to a below-elbow cast for a
further month.
At the recipient site, the bone is osteotomized (if necessary), trimmed, and fitted into the defect. Closing wedge
osteotomies are performed after elevating periosteum and guarding the radial artery with a Freer elevator.
Fixation of the osteotomy is best achieved by a five-hole miniplate applied to the cut surface of the bone. Fixation
of the graft to the recipient mandible may be performed in a number of ways. Miniplates can be used with end-to-
end abutment of a graft to residual mandibular fragments. Alternatively, the mandibular fragments may have their
outer cortices removed and the graft overlapped and lag-screwed to them (Fig. 204.3). The cut surface of the
bone graft is thus brought into contact with decorticated mandibular bone. The final option is to fix the mandibular
fragments with a large reconstruction plate and then trim the graft to fit the interosseous defect. Then it may be
simply wired or screwed to the plate. Any of these methods gives excellent fusion rates (13).

FIGURE 204.3 A: Preoperative photograph of patient with T4 lesion invading mandible and cheek skin, requiring
through-and-through excision. B: Resection including oral mucosa, cheek skin, mandibular body, and angle.
Radial artery and cephalic vein marked on the skin. Two skin paddles are designed to straddle these structures;
their size is estimated using a template of the defect. One paddle will be used for oral lining and the other for
cheek cover. C: Noninnervated osteocutaneous flap isolated on its pedicle. There is sufficient mobility within the
tissues to allow some independent movement of the skin paddles with respect to the bone. D: At termination of
the procedure, both skin paddles are visualized and found to be perfusing well. E: Postoperative radiograph
showing the lag-screw fixation technique. F: Postoperative result. (From Soutar et al., ref. 5, with permission.)
The skin flap is sutured to the intraoral defect using mattress sutures of 3-0 Dexon or Vicryl. Microvascular
anastomoses are performed to the ipsilateral facial artery and external jugular vein, if available. Otherwise,
alternative vessels may be selected (14). The radial forearm flap is one of the few flaps where the arterial and
venous pedicles may simultaneously access opposite sides of the neck.
The lateral antebrachial cutaneous nerve is trimmed and anastomosed to the stump of the ipsilateral lingual
nerve. If this is intact or absent, the inferior alveolar nerve is equally effective. Exposure may require drilling out

the mandibular fragments. Alternatively, an end-to-side anastomosis between the lateral antebrachial cutaneous
nerve and an intact lingual nerve may be attempted, with some expectation of success (15).
CLINICAL RESULTS
The donor defect is cosmetic rather than functional (16) but, when bone is taken, 2-3 months of splinting
are required to lessen the risk of radial fracture. Fear of fracture and limited bone stock explain why this
radial forearm osteocutaneous flap does not enjoy universal acclaim; however, donor defects may be
minimized by meticulous surgical technique, limiting the bone graft to one third of the distal radial
circumference, direct wound closure when possible, and appropriate postoperative splinting.
In low-volume resections, the cosmetic results are excellent and the lap is extremely suitable for a full-
thickness defect. The cosmetic outcome is less satisfactory when the requirement is for bulkier tissue. Bony
defects exceeding 10 cm are probably unsuitable for reconstruction with this flap. Poor results occur when
the indications are exceeded and the patient ends up with a soft-tissue or bony deficiency, particularly
disastrous at the mentum. As with most osteocutaneous free flaps, the external skin paddle is a poor match
for facial skin.
Even though functional impairment has been minimal at the donor site, the radius is significantly weakened
(11), which could be troublesome in manual workers and elderly patients with osteoporosis; however, radial
fracture is uncommon in centers where the flap is routinely used (12) and where appropriate steps are
taken to minimize the risk. Cold sensitivity does not seem to be a problem (16); however, the skin graft is in
a very prominent position, is often subject to delayed healing, and represents a significant cosmetic
deformity. In young members of both sexes, this may be of vital concern.
SUMMARY
The radial forearm osteocutaneous flap is arguably the best flap for the restoration of intraoral function
following oromandibular reconstruction. Extensive amounts of thin, supple skin are available, with excellent
potential for reinnervation.
References
1. Song R, Gao Y, Yu Y, et al. The forearm flap. Clin Plast Surg 1982;9:21.
2. Urken ML, Weinberg H, Vickery C, et al. The neurofasciocutaneous radial forearm flap in head and neck
reconstruction: a preliminary report. Laryngoscope 1990;100:61.
3. Dubner S, Heller KS. Reinnervated radial forearm free flaps in head and neck reconstruction. J Reconstr
Microsurg 1992;8:467.
4. Boyd B, Mulholland S, Gullane P, et al. Lateral antebrachial cutaneous neurosome flaps in oral
reconstruction: are we making sense? Plast Reconstr Surg 1994;93:1350.
5. Soutar DS, Scheker LR, Tanner NSB, McGregor IA. The radial forearm flap: a versatile method for
intraoral reconstruction. Br J Plast Surg 1983;36:1.

6. Boyd JB, Morris SF, Rosen IB, et al. The “through and through” oromandibular defect. Plast Reconstr
Surg 1994;93:44.
7. Boyd JB, Rosen IB, Freeman J, et al. The iliac crest and the radial forearm flap in vascularized
oromandibular reconstruction. Am J Surg 1990; 159:301.
8. Mounsey RA, Boyd JB. Mandibular reconstruction with osseointegrated implants into the free vascularized
radius. Plast Reconstr Surg 1994;94:457.
9. Elliot D, Bardsley AF, Batchelor AG, et al. Direct closure of the radial forearm flap donor defect. Br J Plast
Surg 1988;41:358.
10. Gottlieb LJ, Tachmes L, Pielet RW. Improved venous drainage of the radial artery forearm flap: use of the
profundus cubitalis vein. Ann Plast Surg 1993;9:281.
11. Swanson E, Boyd JB, Mulholland RS. The radial forearm flap: a biomechanical study of the osteotomized
radius. Plast Reconstr Surg 1990;85:267.
12. Weinzweig N, Jones NF, Shestak KC, et al. Oromandibular reconstruction using a keel-shaped
modification of the radial forearm flap. Ann Plast Surg 1994;33:359.
13. Boyd JB, Mulholland RS. Fixation of the vascularized bone graft in mandibular reconstruction. Plast
Reconstr Surg 1993;91:1.
14. Mulholland S, Boyd JB, McCabe S, et al. Recipient vessels in head and neck microsurgery: radiation
effect and vessel access. Plast Reconstr Surg 1993;92:628.
15. Viterbo F, Trindade JC, Hoshino K, Neto AM. End to side neurorrhaphy with removal of the epineural
sheath: an experimental study in rats. Plast Reconstr Surg 1994;94:1038.
16. Smith A, Bowen VA, Rabczak T, Boyd JB. Donor site deficit of the osteocutaneous radial forearm flap.
Ann Plast Surg 1994;32:372.

Chapter 205
Vascularized Rib-Periosteal Transplantation for Reconstruction of
The Mandible and Maxilla
D. SERAFIN
V. E. VOCI
EDITORIAL COMMENT
This technique has now been supplanted by free fibular/scapular osteocutaneous flaps and iliac-crest flaps.
Nonvascularized bone grafts have had reasonable success in small, well-vascularized defects. The major
problem arises when larger defects require large segments of contoured bone and soft-tissue coverage. The rib
is one source of vascularized bone that can be transplanted with or without overlying skin (1, 2).
INDICATIONS
Vascularized rib-periosteal transplantation is indicated to reconstruct a moderate deficiency of the maxilla or
mandible in a relatively avascular bed. The recipient skin envelope must be adequate to accommodate the
relative bulk of the osseous segment and associated bulky musculature.
If the skin envelope is healthy with adequate blood supply and the mandibular or maxillary defect is small to
moderate in size, then a nonvascularized bone graft will provide satisfactory results. If the mandibular or
maxillary segment to be replaced is large with an associated large cutaneous defect, then a vascularized
iliac osteocutaneous flap based on the deep circumflex iliac vessel is the donor tissue of choice (3).
The major advantage of the vascularized rib-periosteal transplant is the ability to provide vascularized
osseous tissue in a relatively avascular bed. Osteocyte survival has been confirmed by subsequent
biopsies, arteriography, and serial radiographs (4, 5, 6). lone union occurs with callus formation similar to
that noted at a fracture site.
ANATOMY
There are nine paired posterior intercostal arteries. They arise from the dorsal aspect of the aorta. At their origin,
they lie midway in the intercostal space and course obliquely upward as they proceed laterally. The arteries on
the right are longer because the aorta lies to the left of the vertebral column. Opposite the heads of the ribs, the
posterior intercostal artery divides into a ventral and dorsal branch (Fig. 205.1). The dorsal branch supplies the
spinal cord, its meninges, and the vertebrae. It then continues dorsally to supply muscular branches to the
paraspinous muscles and cutaneous branches to the skin. The artery of Adamkiewicz arises from one of these
dorsal branches between T7 and L2. This is an extremely important vessel because it provides the major blood
supply to the thoracolumbar spinal cord. Injury to this vessel may result in paraplegia.
Proximally, the ventral branch of the posterior intercostal artery lies between the posterior intercostal membrane
and pleura. By the time it has reached the angle of the rib, however, it has penetrated the posterior intercostal
membrane and internal intercostal muscle and continues anteriorly between the external and internal intercostal
muscles. It courses upward in the interspace obliquely to lie inferior to the corresponding rib and continues
anteriorly in the costal groove between the pleura and the posterior intercostal membrane. It eventually

anastomoses with the anterior intercostal artery, a branch of the internal thoracic artery, at about the
midclavicular line. Each intercostal artery is accompanied by a vein and an intercostal nerve. The vein is superior
and the nerve is inferior to the artery (Fig. 205.2).
The ventral branch gives off multiple branches. The first branch is the nutrient artery to the rib above. This
nutrient branch is given off near the tubercle of the rib and enters the bone through a nutrient foramen (see Fig.
205.1). It quickly divides into proximal and distal medullary arteries in the medullary cavity of the rib. Collateral
intercostal branches are given off at regular intervals, beginning at the angle of the rib. They course down to the
superior border of the rib below, supplying the surrounding soft tissue. Musculocutaneous perforators are also
given off at regular intervals, supplying the pectoralis, serratus, and intercostal muscles as well as the overlying
skin. The overlying skin is also supplied by a lateral cutaneous arterial branch that arises at the midaxillary line
and courses with the lateral cutaneous nerve. The direct and musculocutaneous perforators supply the skin
portion of an osteocutaneous flap. Mammary branches are given off by the third, fourth, and fifth intercostal
arteries.
FIGURE 205.1 The vascular anatomy of the intercostal artery. Note that the artery of Adamkiewicz arises from
one of the dorsal branches between T7 and L2. Also note the location of the nutrient artery to the rib.
The veins on the right side empty into the azygous vein. On the left side, the upper veins empty into the
accessory hemiazygous vein, and the lower veins empty into the hemiazygous vein.
OPERATIVE TECHNIQUE
Three operative approaches have been described for rib-periosteal and osteocutaneous rib grafts: anterior,
posterolateral, and posterior. Each method has advantages and disadvantages.

FIGURE 205.2 A cross section of the rib and the corresponding interspaces. Note the location of the intercostal
vein, artery, and nerve.
Anterior Approach (7, 8)
The donor vessels can be either the anterior intercostal artery and vein (which are often small with multiple
branches) or the internal thoracic artery and vein (both of which have large diameters and lengthy pedicles). The
major advantages are the reliability of a cutaneous portion and accessibility to the head and neck in the supine
position. The main disadvantages include the bulk of the pectoralis major muscle, which must be included, and
the dissection, which is somewhat difficult.
A rib below the fourth is usually selected, so that the dissection of the internal thoracic vessel is facilitated by the
transverse thoracic muscle, which is present below this level. This muscle separates the vessels from the pleura
and therefore makes the dissection somewhat less difficult. If the fifth rib is chosen (1), a small transverse
incision is made over the costochondral cartilage, which is removed subperichondrally, exposing the internal
thoracic vessels and fifth anterior intercostal vessels (Fig. 205.3). The overlying skin island is dissected down to
the rib, preserving the lateral cutaneous nerve, which theoretically can be used to innervate the skin. The bone
then is transected laterally and bluntly dissected off the parietal pleura. Although previous authors indicate that
the dissection is extrapleural, this has not been our experience.
Posterolateral Approach (9, 10)
The flap is based on the posterior intercostal vessels, lateral to the paraspinous muscles. These are usually 1 to
2 mm in diameter. The chief advantages are that the dissection is relatively less difficult than with the other
approaches and the pedicle is quite lengthy. The major disadvantages include the need for an open thoracotomy
incision, the bulk of the muscle cuff, the lack of a reliable cutaneous portion, and the position of the patient,
which limits access to the head and neck region. The ninth or tenth rib is usually selected (2).
With the patient in a lateral thoracotomy position, the incision is made over the chosen rib and extended down
through the anterior portion of the latissimus dorsi muscle for exposure. The appropriate length of rib segment is
delineated. The pleural cavity is entered anteriorly, and the rib is transected. The dissection of the rib and
muscle is then continued posteriorly. Care must be taken to preserve a sufficient muscular cuff around the rib,
especially inferiorly along the vascular pedicle. When sufficient length of bone is obtained, the rib is transected
posteriorly. The pedicle is dissected out as far posteriorly as is necessary to obtain adequate pedicle length.
Fifteen centimeters of pedicle length can be obtained lateral to the paraspinous muscles, depending on the
length of the rib segment (Fig. 205.4). There is no danger of injury to the artery of Adamkiewicz when the

dissection is this far lateral.
FIGURE 205.3 The vascular anatomy of the internal thoracic artery and venae comitantes.
If a cutaneous skin island is required, a previous delay should be performed or multiple cutaneous veins
anastomosed, in addition to the posterior intercostal vein, at the time of transplantation. In a review of
transplanted intercostal osteocutaneous flaps, over half had problems with the skin island.
To provide reliable cutaneous cover, an island latissimus dorsi musculocutaneous flap has been successfully
employed with an attached segment of rib (Fig. 205.5). The osseous segment, however, must be revascularized,
because earlier attempts without revascularization resulted in partial loss of the bone.
Recently, posterolateral rib segments have been successfully transplanted based on blood supply from the
attached serratus muscle. The thoracodorsal artery and vein with branches to the serratus muscle are selected
as the donor vasculature (Fig. 205.6). “Winging” of the scapula does not occur, provided that the superior slips
of origin of the serratus muscle are not violated and the long thoracic nerve of Bell is not injured. A skin island
may be included in the dissection.
FIGURE 205.4 Intraoperative photograph demonstrating rib-periosteal segment. Note the lengthy neurovascular
pedicle (lower left). (From Serafin, Riefkohl, ref. 12, with permission.)
Posterior Approach (5, 11)
The only theoretical advantage to this approach is that the nutrient vessel supplying medullary blood flow is
included. Recent evidence, however, shows that this is not necessary for osteoblast survival and bone healing.
The disadvantages are many, including a very difficult dissection, possible injury to the artery of Adamkiewicz,
the need for a major thoracotomy, and an unreliable cutaneous portion.
The incision is made over the rib (usually the sixth, to avoid injury to the artery of Adamkiewicz), beginning near
the midline of the back and extending laterally. The incision is extended down through the latissimus dorsi and

lateral aspect of the erector spinae muscles. The intercostal muscles in the interspace above are divided, and
the pleural cavity is opened. A similar incision is made in the interspace below, staying close to the rib inferiorly
to ensure safety of the vascular pedicle in the muscular cuff. The length of rib needed is determined, and the rib
is transected laterally. The rib is mobilized enough at this point to visualize the origin of the posterior intercostal
vessels through the pleura. The vessels are isolated through the pleura, ligated, and divided. The dorsal spinal
branch then is ligated and divided near its origin on the posterior intercostal artery. The vascular pedicle is
dissected retrograde, passing it under the sympathetic trunk. The rib can be disarticulated and the thoracotomy
incision closed with a chest tube (Figs. 205.7 and 205.8).
FIGURE 205.5 A: Preoperative photograph of a patient with an orocutaneous fistula subsequent to a composite
resection and postoperative radiation. B: Intraoperative outline of an island latissimus dorsi musculocutaneous
flap with the attached rib periosteal segment. C: Intraoperative photograph demonstrating vascularized rib-
periosteal segment attached to the island latissimus dorsi musculocutaneous flap by loose areolar connective
tissue. The rib-periosteal segment will be revascularized to branches of the external carotid artery and the facial
vein. D: Intraoperative photograph following successful transfer of the island latissimus dorsi musculocutaneous
flap. E: Late postoperative result. (From Serafin, Riefkohl, ref. 12, with permission.)

FIGURE 205.6 The vascular anatomy to the serratus muscle. This muscle, with the associated rib-periosteal
segment, will be transplanted and revascularized at the recipient site. Note that the vascular basis for the
composite tissue is the thoracodorsal artery and vein, with communication to the lateral thoracic artery and vein
by means of a branch to the serratus musculature. Also note the long thoracic nerve that must be carefully
preserved.
FIGURE 205.7 A: Preoperative photograph of a patient following composite resection and postoperative
radiation. B: Radiograph at 4 months demonstrating solid bone union between the remaining segment of
mandible and the rib-periosteal transplant. Note callus formation. C: Intraoral photograph demonstrating results
following vestibuloplasty. Note that vestibuloplasty is possible because of the addition of well-vascularized tissue
to this relatively avascular area. D: Late postoperative result. (From Serafin, Riefkohl, ref. 12, with permission.)

FIGURE 205.8 A: Preoperative photograph demonstrating extensive scarring and relative avascularity
secondary to previous trauma. Note depression of the maxilla. B: Intraoperative dissection of recipient
vasculature through a preauricular incision. C: Intraoperative photograph demonstrating rib-periosteal segment.
Note the vascular clips on the periosteum for subsequent radiographic follow-up. D: Late postoperative result.
(From Serafin et al., ref. 2, with permission.)
CLINICAL RESULTS
Twelve patients (86%) underwent the successful transplantation of a vascularized rib-periosteal segment. In
this series there were two failures (14%). One transplant failed because of inadequate preoperative
planning. The rib selected for transplantation was previously fractured, resulting in an unrecognized
associated injury to the posterior intercostal artery and vein. The other failure occurred postoperatively.
This patient developed severe hematemesis. During the course of frequent vomiting, both anastomoses
were disrupted. This was confirmed by reexploration later in the postoperative period.
A major disadvantage is the lengthy operative procedure, often with attendant thoracic morbidity. Other
disadvantages include the structural weakness of the transplanted rib segment, a deficient quantity of bone,
and an obligatory large, bulky muscular cuff that must be included with the rib- periosteal segment to ensure
adequate cortical circulation. The associated cutaneous segment using the posterolateral approach is
unreliable.
SUMMARY

Vascularized osseous transplantation has a definite but limited role in reconstruction of the head and neck
subsequent to tumor ablation and trauma.
References
1. Buncke, HJ, Furnas DW, Gordon L, Achauer BM. Free osteocutaneous flap from a rib to the tibia. Plast
Reconstr Surg 1977;59:799.
2. Serafin D, Riefkohl R, Thomas I, Georgiade NG. Vascularized rib-periosteal and osteocutaneous
reconstruction of the maxilla and mandible: an assessment. Plast Reconstr Surg 1980;66:718.
3. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free
groin flaps. Plast Reconstr Surg 1979;61:745.
4. Berggren A, Weiland AJ, Dorfman H. Free vascularized bone grafts: factors affecting their survival and
ability to heal to recipient bone defects. Plast Reconstr Surg 1982;69:19.
5. Östrup LT, Fredrickson JM. Reconstruction of mandibular defects after radiation, using a free, living bone
graft transferred by microvascular anastomoses: an experimental study. Plast Reconstr Surg 1975;55:563.
6. Ostrup LT. Rib transplantation. In: Serafin D, Buncke HJ Jr, eds. Microsurgical composite tissue
transplantation. St. Louis: Mosby, 1979.
7. Ariyan S, Finseth FJ. The anterior chest approach for obtaining free osteocutaneous rib grafts. Plast
Reconstr Surg 1978;62:767.
8. McKee DM. Microvascular rib transplantation in reconstruction of the mandible. Presented at the Annual
Meeting of the American Society of Plastic and Reconstructive Surgeons, Montreal, Canada, 1971.
9. Harashina T, Nakajima H, Imai T. Reconstruction of mandibular defects with revascularized free rib grafts.
Plast Reconstr Surg 1978;62:514.
10. Serafin D, Villareal-Rios A, Georgiade NG. A rib-containing free flap to reconstruct mandibular defects. Br
J Plast Surg 1977;30:263.
11. Daniel RK. Mandibular reconstruction with free tissue transfers. Ann Plast Surg 1978;1:346.
12. Serafin D, Riefkohl R. In: Serafin D, Buncke HJ, Jr, eds. Microsurgical composite tissue transplantation.
St. Louis: Mosby, 1979.

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Chapter 206
Microvascular Free Transfer of Serratus Anterior and Rib
Composite Flap
W. C. LINEWEAVER
F. ZHANG
A. KELLS
EDITORIAL COMMENT
This flap has its most important application in mandibular defects and potentially only as a salvage
procedure in lower extremity defects.
The serratus anterior-rib composite flap is a versatile flap with use in reconstruction of both bone and soft-tissue
defects. Clinical applications have shown that the serratus anterior-rib composite flap offers a long thoracodorsal
vascular pedicle, large pedicle vessels for anastomoses, relatively simple dissection, soft-tissue coverage
without large muscle bulk, and a favorable donor site.
INDICATIONS
By using the serratus as the source of rib blood supply and the thoracodorsal vessels as the pedicle, the
serratus anterior-rib composite flap avoids the disadvantages of the short internal mammary or the posterior
intercostal pedicles of microvascular rib osseous or osteocutaneous flaps (1, 2). Based on its cross-
sectional area and curved shape, the rib is an excellent source of vascularized bone to reconstruct defects
of the facial bones, particularly the mandible. The serratus anterior-rib composite flap is suitable for repair of
mandibular defects with soft-tissue loss, either of the floor of the mouth or of the chin or neck (3). The
circumferential thickness of rib and its general shape are also similar to what is found in metacarpal and
metatarsal bones. The serratus-rib composite flap can provide an excellent resource for reconstruction of
metacarpal and metatarsal defects with associated soft-tissue defects (4, 5).
In reconstruction of segmental long-bone defects of the lower extremity, vascularized fibular
osteoseptocutaneous flaps are generally recommended as the first choice, because the fibular flap has
several advantages (6, 7, 8). However, when the fibular flap is not available and the bone defects are
greater than 10 cm, serratus anterior-rib flaps become useful alternative flaps. Because the rib flap is
curved, rather than straight, and has a limited cross-sectional area to withstand body
weight-load, indications in lower-extremity reconstruction at this point are (a) bilateral tibial fibular defects
greater than 10 to 12 cm; (b) extensive composite defects of bone and soft tissue; and (c) contralateral
fibula damage, making the vascular anatomy and dissection unreliable and difficult. The flap may need to
be extended to include two or three ribs, to provide more strength and to support axial weight-bearing (9,
10).
ANATOMY
The serratus anterior muscle is located on the lateral thoracic wall. Its fibers arise from the outer surfaces of the

upper 9 to 10 ribs anterolaterally and insert into the medial border of the scapula. The serratus anterior muscle
receives a dual blood supply. The lateral thoracic artery, located anterior to the subscapular-thoracodorsal
artery, enters the lateral surface of the muscle and then courses anteriorly with multiple branches into the
muscle. The second blood supply is via the thoracodorsal artery, which has branches to the serratus anterior.
Studies of dissections of the thoracodorsal artery showed that in 99% of cases, the thoracodorsal artery gave off
one or more branches to the serratus anterior muscle (11). Rarely, this serratus pedicle can branch off directly
from the axillary vessels (12).
The rib has a dual blood supply that includes nutrient vessels from the posterior intercostal artery, as well as a
periosteal blood supply through the serratus anterior muscle from the serratus anterior branch of the
thoracodorsal artery (13). Dye-injection studies of the thoracodorsal system demonstrate continuity between the
serratus branch and the intercostal arteries through the periosteal vessels. Arteriograms through the distal
thoracodorsal arteries also show consistent filling of the lower sixth to ninth intercostal vessels from the serratus
muscle perforators. These findings further demonstrate consistent communication between the serratus branch
and the intercostal arteries through the periosteal vessels (5).
FLAP DESIGN AND DIMENSIONS
With the patient placed in the lateral position, the flap is planned anterior to the anterior axillary line and is
centered over the sixth rib, with extensions above and below the fifth and seventh ribs. The lower the rib is
taken, the longer the pedicle obtained. If necessary, a skin paddle of approximately 6 × 12 cm overlying the ribs
can be elevated. For lower-extremity reconstruction, one rib graft is too weak to support body weight. Two or
three sections of ribs may be used, to provide more strength and to support axial weight-bearing.
OPERATIVE TECHNIQUE
Initial elevation of the flap is via a midaxial anterior skin flap incision. The anterior border of the latissimus dorsi
muscle is identified and retracted posteriorly. The thoracodorsal vessels are exposed between the posterior
surface of this muscle and the serratus anterior. The serratus branch of the thoracodorsal is traced to the
desired muscle segment. The serratus muscle is then dissected from the scapula. Generally, the cephalad four
slips of the serratus muscle are left intact to anchor the scapula, and the flap is composed of the distal slips.
At the designed rib-muscle segment, the intercostal neurovascular bundle can be easily identified (Fig. 206.1).
Adequate intercostal muscles are left with the periosteum of the chosen rib, particularly at the lower border, to
preserve the neurovascular bundle. The rib is then transected immediately lateral to the costochondral junction.

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FIGURE 206.1 Operative exposure for flap harvest.
The extrapleural dissection may be difficult because the parietal pleura is densely adherent to the posterior rib
periosteum. It may be necessary to sacrifice a portion of the pleura in order to preserve the periosteum. In this
situation, the pleura has to be closed by approximating the adjacent ribs, and temporary chest-tube placement is
necessary. If two ribs are to be used, harvesting alternative ribs is better than harvesting consecutive rib
segments. If three ribs are harvested, the continuous two-rib defect should be protected with a sheet of synthetic
Marlex mesh or lyophilized dura, to reinforce the chest wall.
The serratus anterior-rib composite flap is now isolated on the serratus branch of the thoracodorsal pedicle,
which is dissected proximally toward the axilla and can be divided at an appropriate level.
CLINICAL RESULTS
In 1984, Richards et al. (3) reported seven cases of microvascular free and pedicled transfer of rib
composite flaps, with overlying muscle for reconstructions of mandibular defects caused by injury, tumor
resection, and hemifacial microsomia (Fig. 206.2). In mandibular reconstruction, the vascularized rib was
eminently suitable, as lengths of bone between 12 and 16 cm are required. Long segments of rib can be
bent by green-stick fracturing, after making cuts on the inner cortex. The reconstructions were proved solid
and looked satisfactory on radiographs. Loss of soft tissue of the flap was reported in two of seven cases.
Buncke's group (2, 14) also reported successful mandibular reconstruction with microvascular serratus-rib
composite free-flap transfer. In a typical case, 18 cm of the sixth rib was contoured into place, by
subperiosteal scoring and screw fixation, to the remnant left side of the mandible, after
resection of a malignant histiocytoma of the right side of the mandible. Postoperative follow-up showed
bony restoration.
FIGURE 206.2 Flap inset for mandibular reconstruction (pedicle vessels are anastomosed to the facial
vessels).
In 1999, Hui et al. (5) reported two cases of microvascular serratus-rib composite free-flap transfers for
reconstruction of the first metacarpal bone. In these cases, the ribs were placed in the metacarpal defect
and secured with Kirschner wires. The first metacarpophalangeal joint was fused. Subsequent healing was

uneventful. The results showed that the vascularized rib graft offers ideal structural support, and the
circumferential thickness is similar to that of the metacarpal. This flap offers a long vascular pedicle with
less muscle bulk in reconstruction of hands with metacarpal and soft-tissue defects. Moscona et al. (4) and
Bruck et al. (13) also reported similar results of microvascular serratus-rib composite free-flap transfers for
metatarsal reconstruction. In these cases, the ribs were also fixed in placed by axial Kirschner wires.
Postoperative technetium-99 bone scan showed good perfusion, and radiographs confirmed union of the
metatarsal bones.
Lin et al. (9, 10) reported serratus anterior rib flaps that were used for composite tibial bone and soft-tissue
reconstruction in 22 patients. Two of these patients underwent bilateral serratus anterior rib flaps for
bilateral tibia-fibular open grade IIIB fractures. The number of ribs harvested varied between one and three,
depending on the bone defect. The limbs were protected with a brace and with crutch ambulation for up to 1
year, until adequate hypertrophy of the ribs occurred. The results showed that 21 of 24 flaps survived
completely. Fifteen of 21 flaps had primary bone union and hypertrophy of the bone. The unhealed tibias
were treated with secondary conventional bone grafting or Ilizarov bone transportation.
In addition to recipient complications such as flap loss, nonunion, osteomyelitis, and stress fracture, donor-
site morbidities, including pneumothorax, pleural fibrosis, chest-wall deformities, and chronic chest pain, are
rarely reported. Generally, the donor site is inconspicuous and asymptomatic.
SUMMARY
The serratus anterior-rib composite flap, with the advantages of a long thoracodorsal vascular pedicle,
simple dissection, soft-tissue coverage without large muscle bulk, and low donor-site complications, can
provide excellent bone and soft tissue for reconstruction of mandible, metacarpal, and metatarsal defects
combined with soft-tissue loss. When the fibular flap is not available and bone defects are greater than 10
cm, serratus anterior-rib flaps become a useful alternative for repair of tibial bone and soft-tissue defects.
References
1. Buncke HJ, Furnas DW, Gordon L, et al. Free osteocutaneous flap from a rib to the tibia. Plast Reconstr
Surg 1977;59:799.
2. Buncke HJ. Rib microvascular transplantation. In: Buncke HJ, Ed., Microsurgery: transplantation-
replantation. Philadelphia: Lea & Febiger, 1991;350-367.
3. Richards MA, Poole MD, Godfrey AM. The serratus anterior/rib composite flap for mandibular
reconstruction. Br J Plast Surg 1985;38:466.
4. Moscona RA, Ulhmann Y, Hirshowitz B. Free composite serratus anterior muscle-rib flap for reconstruction
of the severely damaged foot. Ann Plast Surg 1988;20:167.
5. Hui KC, Zhang F, Lineaweaver WC, et al. Serratus anterior-rib composite flap: anatomic studies and
clinical application to hand reconstruction. Ann Plast Surg 1999;42:132.
6. Malizos KN, Nunley JA, Goldner RD, et al. Free vascularized fibula in traumatic long bone defects and in

limb salvaging following tumor resection: comparative study. Microsurgery 1993;14:368.
7. Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft tissue defects in traumatic
lower extremities. Plast Reconstr Surg 2004;114:1457.
8. Pollock R, Stalley P, Lee K, Pennington D. Free vascularized fibula grafts in limb salvage surgery. J
Reconstr Microsurg 2005;21:79.
9. Lin CH, Wei PC, Levin S, et al. Free composite serratus anterior and rib flaps for tibial composite bone and
soft-tissue defect. Plast Reconstr Surg 1997;99:1656.
10. Lin CH, Yazar S. Revisiting the serratus anterior rib flap for composite tibial defects. Plast Reconstr Surg
2004;114:1871.
11. Rowsell AR, Davies DM, Eisenberg N, Taylor GI. The anatomy of the subscapular thoracodorsal arterial
system: study of 100 cadaver dissections. Br J Plast Surg 1984;37:574.
12. Goldberg JA, Lineaweaver WC, Buncke HJ. An aberrant independent origin of the serratus anterior
pedicle. Ann Plast Surg 1990;25:487.
13. Bruck JC, Bier J, Kistler D. The serratus anterior osteocutaneous free flap. J Reconstr Microsurg
1990;6:209.
14. Whitney TM, Buncke HJ, Alpert BS, et al. The serratus anterior free-muscle flap: experience with 100
consecutive cases. Plast Reconstr Surg 1990; 86:481.

Chapter 207
Microvascular Transfer of The Compound Dorsalis Pedis Skin
Flap With Second Metatarsal for Mandible and Floor of Mouth
Reconstruction
R. M. ZUKER
R. T. MANKTELOW
EDITORIAL COMMENT
Care must be taken in closure of the donor site to prevent late donor-site problems. By releasing the
tendons laterally and medially and shifting them toward the midline, the bony defect can be covered. A skin
graft then can be placed over this vascularized surface.
Perhaps one of the most significant contributions to head and neck reconstruction is the use of the free
composite osteocutaneous flap (1, 2, 3, 4, 5, 6, 7, 8). The dorsalis pedis flap (9, 10), when used with the second
metatarsal, can reconstruct not only the floor of the mouth but also up to 8 cm of the mandible itself with
vascularized tissue.
INDICATIONS
Reconstruction of head and neck defects is most difficult following composite resections. There are
occasions when no bony reconstruction of any kind is mandatory, such as hemi-mandibular resections. We
believe reconstruction with vascularized bone provides the patient with the best reconstructive alternative.
Thus, a hemimandibular resection would be a relative indication.
Anterior segment defects, on the other hand, leave the patient with a significant functional and aesthetic
deformity that requires reconstruction. Conventional techniques often fall short of providing adequate,
lasting bone for both contour restoration and function. Problems may ensue with mastication, the production
of intelligible speech, and drooling. The dorsalis pedis flap with the metatarsal, when osteotomized,
provides an excellent reconstructive tool for the anterior segment defect, one that cannot be provided by
any other available means of reconstruction. The anterior segment composite resection, then, does provide
an absolute indication for the compound dorsalis pedis skin and metatarsal flap, provided that the bony
defect can be reconstructed with the 7 to 8 cm of metatarsal available.
Among advantages of the flap are that it provides vascularized bone for difficult reconstructive problems
such as anterior segment defects. It also provides thin, pliable tissue for mucosal resurfacing, a long
vascular pedicle, and a donor site that is remote from the recipient site, which may have been radiated.
FLAP DESIGN AND DIMENSIONS
With postoperative lingual swelling, the pedicle could be compromised seriously if its position were between the
tongue and mandible. Thus, it is better to have the vascular pedicle external to the mandible. The most likely site
of recipient vasculature is identified. Because the position of the vessels should be external to the mandible, it is
best to use the contralateral foot. Routine angiography is not necessary if adequate independent dorsalis pedis
and posterior tibial pulses are present.

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The boundaries of the skin flap include the extensor retinaculum proximally, the interdigital web spaces distally,
and 1 cm on either side of the extensor hallucis longus (medially) and extensor digiti quinti (laterally). The second
metatarsal then lies beneath the central segment of the skin flap (see Fig. 207.2B).
OPERATIVE TECHNIQUE
The operation is carried out in three parts. The tumor (Fig. 207.1A) is resected along with the anterior segment
of mandible. Usually, a lip-splitting approach is used (Fig. 207.1B). A radical neck dissection is often necessary,
and the recipient vasculature is prepared on this side. We have used virtually all the branches of the external
carotid artery to revascularize this flap. Usually, however, the superior thyroid or facial vessels, if available, are
used. To assist in the mandibular reconstruction, the mandible that has been resected is measured on either
side of the midline and its angle at the
anterior segment is estimated. A template of this resected segment may be useful in planning the osteotomy of
the second metatarsal.
FIGURE 207.1 A: Squamous cell cancer of sulcus with mandibular involvement. B: Defect after resection of
tumor.
Donor Site
The dissection begins distally between the first and second toes, where the first dorsal metatarsal artery is
identified (11). This usually lies in the interosseous musculature on a superficial plane. This vessel, then, will be
visualized throughout the dissection, and it and any musculature that lies between it and the second metatarsal
should be included in the flap.
The extensor tendons to the second toe are divided at the metatarsophalangeal level, and this joint is entered.
The second metatarsal is included with the skin flap with transection of the intermetatarsal ligaments and the
interosseous musculature along the adjacent borders of the first and third metatarsi.
The skin flap is elevated just superficial to the paratenon overlying the extensor tendons. The fine attachments
between the second metatarsal and the skin flap are maintained. The extensor tendons to the second toe remain
on the foot to aid in closure. With elevation from distal to proximal, the extensor hallucis brevis tendon is
encountered. Because this tendon lies between the skin flap and the first dorsal metatarsal artery, it must be
maintained in the flap.
At the medial border of the dissection, care is taken to maintain continuity between the flap and the long
saphenous vein. The decision regarding venous drainage will be made at the termination of the dissection, but
during elevation, both the long saphenous vein and the venae comitantes of the anterior tibial-dorsalis pedis-first
dorsal metatarsal vascular system must be maintained.

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The dissection then proceeds proximally to the base of the second metatarsal. Extreme care must be taken at
this point not to damage the perforating branch of the dorsalis pedis artery and to preserve the takeoff of the first
dorsal metatarsal artery within the flap. The first dorsal metatarsal artery originates from the dorsalis pedis artery
as it passes over the second cuneiform bone and plunges down to the plantar arch (see Anatomy, Chapter 288).
The perforator must be visualized and transected deep to the takeoff of the first dorsal metatarsal artery. This
latter vessel, along with the interosseous musculature adjacent to the second metatarsal, must be maintained in
the flap.
Before complete separation of the bone, it is helpful to isolate the dorsalis pedis artery and its venae comitantes.
The proximal skin incision is made, and the superficial peroneal nerves are sacrificed. This flap has the potential
for innervation should this be desirable. The proximal bony attachments at this point are divided. The capsular
attachments to the cuneiforms and adjacent metatarsi are transected using a no. 11 blade. Extreme care is taken
to protect the dorsalis pedis vessels, the perforating branch, and the first dorsal metatarsal vessels.
Patience is necessary at this point to free the bone from its dense fibrous capsular attachments. Once the bone
is freed, the flap attachments consist of only the long saphenous vein and the dorsalis pedis artery and its venae
comitantes. Through a more proximal curvilinear incision, the extensor retinaculum is incised, facilitating
dissection of the dorsalis pedis vessels and, more proximally, the anterior tibial vessels. The vascular pedicles
are dissected to the length required (Fig. 207.2B). The circulation within the flap is allowed to stabilize before
definitive flap separation. The flap is completely separated from the foot and transferred to the recipient site.
Donor-site closure of the foot must not be undertaken lightly. Much of the criticism directed toward this flap has
been in regard to difficult donor-site problems, which can be avoided by using proper closure technique. After
complete hemostasis has been obtained, the first and third metatarsi are approximated distally using heavy wire
or Mersilene sutures. The second toe is amputated with approximation of the first and second web spaces. To
obtain a healthy, vascularized bed for skin grafting, the tendon and paratendinous tissue must be approximated.
Two bipedicled tendon flaps are elevated. The medial one consists of only the extensor hallucis longus with its
paratenon. The lateral flap consists of the extensor tendons to the second, third, fourth, and fifth toes as well as
the surrounding paratenon. Bipedicle flaps are elevated directly above the periosteum. These flaps then are
mobilized and directed toward each other to form a continuous vascularized surface. They are approximated with
heavy absorbable sutures. All rents in the paratenon must be closed with fine absorbable sutures.
An even vascularized bed then is prepared for grafting (Fig. 207.2). We prefer a medium-thickness split-
thickness skin graft, which is held in place with a tieover bolus dressing.
The ankle is maintained in the neutral position with a posterior slab. Elevation and bed rest are maintained for 10
days.

FIGURE 207.2 A: The compound dorsalis pedis skin flap with second metatarsal. B: Flap elevated on vascular
pedicle. C: Donor site prepared for split-thickness skin grafting.
Recipient Site
The flap is transferred to the head and neck area. All bony work must be done before revascularization. In a
hemiman-dibular reconstruction, osteotomy is rarely necessary. The length of the resected mandible then is
reconstructed using a similar length of metatarsal. The cartilaginous surface at either end of the metatarsal is
removed, so that a direct end-to-end apposition of bone can be achieved. It is best to use as much cancellous
segment of the metatarsal as possible for the osteosynthesis. We prefer two interosseous wire loops at either
end for bony fixation.
For anterior segment defects, an osteotomy is almost always necessary. The osteotomy need not be
symmetrical, as the endosteal blood supply to the metatarsal enters at either end. The periosteal blood supply is
also maintained. Accurate lengths of the resected segment then are planned for the reconstruction. The site and
angle of the osteotomy are outlined. We prefer a closing-wedge osteotomy (Fig. 207.3A) that is maintained by
two interosseous wire loops. Final tightening and adjustment of these wire loops are left until the bone has been
wired in place.
The cartilage from either end of the metatarsal is removed, so that direct apposition between the metatarsal and
the residual mandible can be achieved. Again, maximal cancellous contact is preferable. Two accurately placed
interosseous wire loops provide for bony fixation at either end (Fig. 207.3B). The residual mandibular segments
should be placed in as near preoperative occlusion as possible. In this way, optimal chin projection can be
achieved.
Once the final adjustments and tightening of the wires are done, the flap is revascularized. Generally, the long
saphenous vein is used as the venous drainage system; however, if it is small and the vena comitans of the
anterior tibial artery is of sufficient size, the vena comitans is used. One artery and one vein are all that are
required for anastomosis. With release of the clamps, revascularization is evident not only in the skin but also
from the prepared bone ends and the muscle cuff around the second metatarsal.
The skin flap is then definitively sutured in place with watertight interrupted mattress sutures (Fig. 207.3C). The
neck flaps are repositioned with appropriate suction drainage. Great care in oral hygiene is maintained for 2

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weeks until oral intake is permitted. A nasogastric tube is sufficient to provide adequate nutritional intake. The
skin flap is thin and pliable and thus contours well over the metatarsa. The late reconstructive results are
excellent in terms of soft-tissue cover and chin projection (Fig. 207.3D and E).
CLINICAL RESULTS
Donor-site healing problems may occur if care is not taken in donor-site closure. Also, this is a difficult flap
to elevate.
SUMMARY
The dorsalis pedis skin flap with second metatarsal may be useful for composite floor of the mouth and
mandibular defects. It is particularly helpful where conventional bone grafting is unlikely to succeed (anterior
segment in radiated bed) and the aesthetic and functional consequences of inadequate reconstruction
would be disastrous.
FIGURE 207.3 A: Closing wedge osteotomy of second metatarsal. B: Note course of pedicle external to
bone. C: Dorsalis pedis skin flap draped over bone and sutured in place. D: Late result. Note intraoral flap
and adequate chin projection. E: Radiograph of reconstructed mandible.

References
1. Gilbert A. Composite tissue transfers from the foot: anatomic basis and surgical technique. In: Daniller A,
Strauch B, eds. Symposium on microsurgery. St. Louis: Mosby, 1976;230.
2. May JW Jr, Chait LA, Cohen BE, O'Brien BM. Free neurovascular flap from the first web of the foot in hand
reconstruction. J Hand Surg 1977; 2:387.
3. Morrison WA, O'Brien BM, MacLeod AM. The foot as a donor site in reconstructive microsurgery. World J
Surg 1979;3:43.
4. O'Brien BM, Morrison WA, MacLeod AM, Dooly BJ. Microvascular osteocutaneous transfer using the groin
flap and iliac crest and the dorsalis pedis flap and second metatarsal. Br J Plast Surg 1979;32:188.
5. Zuker RM, Manktelow RT, Palmer JA, Rosen IB. Head and neck reconstruction following resection of
carcinoma using microvascular free flaps. Surgery 1980;88:461.
6. Zuker RM, Rosen IB, Palmer JA, et al. Microvascular free flaps in head and neck reconstruction. Can J
Surg 1980;23:157.
7. Bell MSG. New method of oral reconstruction using a free composite foot flap. Ann Plast Surg 1980;5:281.
8. MacLeod AM, Robinson DW. Reconstruction of defects involving the mandible and floor of mouth by free
osteocutaneous flaps derived from the foot. Br J Plast Surg 1982;35:239.
9. McCraw JB, Furlow LT. The dorsalis pedis arterialized flap. Plast Reconstr Surg 1975;1:177.
10. Duncan MJ, Manktelow RT, Zuker RM, Rosen IB. Mandibular reconstruction in the radiated patient: the
role of osteocutaneous free tissue transfers. Plast Reconstr Surg 1985;76:829.
11. Ohtsuka H. Angiographic analysis of the first metatarsal artery. Ann Plast Surg 1981;7:2.

Chapter 208
Microvascular Free Transfer of A Compound Deep Circumflex
Groin and Iliac Crest Flap to The Mandible
G. I. TAYLOR
R. J. CORLETT
EDITORIAL COMMENT
This is an outstanding, now classic description of the compound transfer of bone and soft tissue for facial
bone reconstruction. The results are spectacular and speak for themselves. The problems associated with
this flap are obviously the need to be expert in microvascular surgery and, specifically, the need to transfer
a bulky flap with very little free mobility of the overlying skin. This may present some problems in planning
the reconstruction.
The vascular territory of the deep circumflex iliac artery encompasses a large amount of skin and bone that can
be used for one-stage transfer with reliability. The bone graft is well vascularized and provides excellent contour
for the mandible, and the donor site has minimal morbidity (1, 2). In addition to skin, other soft-tissue elements
can be harvested with a common blood supply to provide a functional as well as an aesthetic result. This
composite graft is best suited for the difficult problems encountered in head and neck reconstruction (3, 4, 5).
INDICATIONS
There have been many significant advances in the past 20 years in reconstruction of major defects of the
mandible and the associated soft tissues (6, 7, 8, 9). Initially, the forehead and deltopectoral flaps improved
soft-tissue repair. They provided better coverage for nonvascularized bone grafts, taken usually from the
iliac crest or the rib. Their reliability fell dramatically, however, if the area was heavily irradiated. The
musculocutaneous flap provides additional bulk, as well as vascularized muscle, to cover the carotid
vessels; however, the supply to associated bone segments has not proved to be reliable.
Although a number of donor sites have been used for this purpose, we believe that the iliac crest flap,
designed initially on the superficial circumflex iliac artery and, more recently, on the deep circumflex iliac
artery, has a number of advantages, especially when the bone gap is considerable. Large amounts of both
iliac bone and groin skin are available from an area that has minimal donor-site morbidity, both cosmetic
and functional.
The vessels for anastomosis are large, ranging from 1.5 to 3.0 mm in diameter, permitting reliable
anastomoses. The pedicle is long, from 5.0 to 9.0 cm. The anatomy is familiar to most surgeons. Not only is
the iliac crest the ideal shape for mandibular reconstruction, but sufficient bone is available in an adult to
reconstruct an entire mandible with a vascularized graft from one hip.
The bone can be contoured or split, or appropriate osteotomies can be performed to obtain an exact replica
of the jaw. Also, soft tissue other than skin may be included in the graft design to reconstruct muscle and
ligamentous attachments to the lower jaw.
ANATOMY

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The deep circumflex iliac artery arises from its posterolateral side at the level of the inguinal ligament. The artery,
together with its paired venae comitantes, courses upward and laterally in its own fascial sheath behind the
inguinal ligament toward the anterior superior iliac spine (Fig. 208.1). The paired venae comitantes join to form a
single vein 2 to 3 cm lateral to the external iliac artery. This vein then characteristically diverges upward from its
artery to reach the external iliac vein. In so doing, it crosses either in front of or behind the external iliac artery. At
this point of divergence, there is usually a communication with one of the venae comitantes of the superficial
circumflex iliac artery.
Approximately 1 cm medial to the anterior superior iliac spine, a large ascending muscular branch is given off.
This vessel pierces the transversus muscle and the internal oblique. It may be found reliably 1 cm above and
lateral to the anterior superior iliac spine. Rarely, the deep circumflex iliac vessels may lie in a more superficial
plane, and when this occurs, the variation usually is associated with an abnormal obturator artery.
FIGURE 208.1 Diagram of the deep circumflex iliac artery with its periosteal supply to the inner cortex of the ilium
and the musculocutaneous perforators that pierce the three muscles of the abdominal wall at intervals to nourish
the overlying skin. The iliacus muscle is cross-batched. (From Taylor et al., ref. 2, with permission.)
The musculocutaneous perforators to the skin arise from the parent artery as it lies adjacent to the inner aspect
of the ilium. They penetrate the muscles beyond the anterior superior iliac spine and emerge from the external
oblique in a row approximately 1 cm above the iliac crest. The terminal part of the deep circumflex iliac artery
usually emerges as the largest perforator 8 to 10 cm from the anterior superior iliac spine.
The deep circumflex iliac artery is 1.0 to 1.5 mm in diameter and is usually suitable for anastomosis. It can be
used to provide a distal runoff from the graft or to connect to another vessel (e.g., the superficial circumflex iliac
artery) to augment cutaneous circulation. After division of the three layers of the abdominal wall, the deep
circumflex iliac artery will be found situated in the fold between the overhanging transversus muscle and the
iliacus.
FLAP DESIGN AND DIMENSIONS
We perform angiography on most patients, which provides valuable information on both the donor and recipient
vessels (Fig. 208.2). It outlines the effects of previous surgery, radiation, or tumor expansion on the vascular
anatomy. The finding of an abnormal obturator artery in the groin is a preoperative warning that the course of the

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deep circumflex iliac artery may be more superficial than normal, although we have yet to encounter this in a
clinical case.
The presence or absence of suitable recipient vessels on one side of the neck is noted after neck dissection or
radiation therapy, and this predicts the need for vein grafts or a modification of graft design.
FIGURE 208.2 Angiogram showing the characteristic “paintbrush stroke” of the deep circumflex iliac artery
passing upward and laterally at 45 degrees from the region of the hip joint. (From Taylor, Daniel, ref. 11, with
permission.)
An acrylic pelvis with detachable iliac crests is a useful aid when selecting the donor hip for planning the correct
orientation of the graft. A methyl methacrylate replica of the bone defect is made preoperatively and used both in
the planning and as a preoperative check of the size and shape of the graft both at the donor and recipient sites
(Fig. 208.4). The mandible may be designed from the iliac crest in one of three ways, depending on the length of
graft required and the position of the vascular pedicle (see Fig. 208.1).
1. The usual method uses the ipsilateral hip. The lower jaw is designed in such a way that the anterior superior
iliac spine becomes the angle of the mandible, the anterior inferior iliac spine becomes the head, and the iliac
crest becomes the body of the mandible. The vascular pedicle will be situated behind the new angle of the
jaw. Here it is readily accessible for anastomosis to one of the branches of the external carotid system (e.g.,
the facial artery). This design allows the greatest length of graft to be obtained for mandibular construction. A
wedge or step osteotomy is performed in the midline to adjust the curvature of the bone when the graft
extends beyond the chin (Fig. 208.5, left).
2. For reconstruction of short mandibular segments, the bone graft may be designed so that the anterior iliac
crest becomes the ramus of the jaw and the bone between the anterior superior iliac spine and the anterior
inferior iliac spine becomes the body (Fig. 208.5, center).
3. Alternatively, the first pattern can be reversed so that the ramus is contoured from the posterior ilium and the
body from the anterior part of the crest. This places the pedicle near the midline, and it will reach vessels on
the opposite side of the neck. Because of the curvature of the crest, the graft must be designed from the
opposite hip (Fig. 208.5, right).

FIGURE 208.3 The three methods of designing the ramus and body of the mandible from the ilium. The first and
third technique place the vascular pedicle (arrow) at the angle of the jaw. The second method sites the graft
pedicle at the jaw midline, where it will reach recipient vessels on either side of the neck. (From Taylor, ref. 12,
with permission.)
Despite all preoperative planning outlined, it may be difficult to anticipate some of the three-dimensional
problems encountered during actual surgery. Rehearsal of the operation on a fresh cadaver has been invaluable
in solving these problems before entering the operating room.
A plastic foam replica of the skin defect is shaped, and this pattern is transferred to the hip, taking care to center
it over the skin perforators. The skin flap is marked two thirds above and one third below the line of the anterior
iliac crest. The flap will survive as far medially as the femoral vessels, but it must incorporate the perforators that
emerge above the iliac crest between 2 and 8 cm from the anterior superior iliac spine. The acrylic model is used
to outline the bone graft. Doppler studies can be used to locate the recipient vessels in the neck.
FIGURE 208.4 Bone models used in planning. A: The curve of the iliac crest matches the lower border of the
body of the mandible to the chin and then veers away. B: Osteotomy performed from the outer cortex to recreate
the chin contour. This may be done as a step or a wedge osteotomy. C: The graft model used to plan case 1.
Note the keystone of bone at the chin point. D: The graft model used for case 2. The graft was split from the
inner aspect of the ilium to leave the outer cortex and hemiapophysis for normal hip contour and growth. (From

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Taylor, ref. 10, with permission.)
OPERATIVE TECHNIQUE
The dissection of the graft is conveniently divided into four steps: (a) a medial isolation of the pedicle, (b) an
upper lateral division of the muscles of the anterior abdominal wall, (c) a lower lateral separation of the upper
thigh muscles, and (d) a deep section of the ilium (Figs. 208.5, 208.6, 208.7, 208.8, 208.9, 208.10, 208.11,
208.12, 208.13, 208.14).
Medial Dissection
In the medial dissection, the skin is incised directly over the inguinal canal, and the external ring is located. The
external oblique aponeurosis is split parallel to and 1 cm above the free edge of the inguinal ligament. The
external iliac artery is palpated through the posterior wall of the inguinal canal.
The pedicle is dissected laterally, dividing the arching fibers of the internal oblique and the transversus muscles
from the inguinal ligament. It is often useful to look for the large ascending muscular branch of the deep
circumflex iliac artery (reliably found 1 cm above and lateral to the anterior superior iliac spine) early in the
dissection and trace it down to the main pedicle.
FIGURE 208.5 Case 1. The procedure. Left: Resection of the entire mandible except the right ramus, together
with the tumor, the metal prosthesis, and the soft tissues from the lower lip to the level of the hyoid bone. Center:
The graft designed from the ipsilateral hip. A segment of the rectus femoris tendon, A, provides capsular
ligaments for the temporomandibular joint. A flap of fascia lata, B, allows reattachment of the masseter muscle. A
coronoid process, C, is shaped from the blade of the ilium to secure the temporalis tendon. An osteotomy is
made in the midline to recreate the chin and is secured with a free bone keystone. The bone is step-cut at point
D for fixation to the right ramus. Right: The graft in position with vein grafts needed to reach normal recipient
vessels on the opposite side of the neck.
Upper Lateral Dissection

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In the upper lateral dissection, to retain the musculocutaneous perforators to the skin, a 1.5- to 2.0-cm-wide strip
of the three abdominal wall muscles is left attached to the bone, extending posteriorly for 8 to 10 cm. During the
course of this dissection, the ascending branch of the deep circumflex iliac artery is encountered. After division of
the three layers of the abdominal wall, this artery will be found situated in the fold between the overhanging
transversus muscle and the iliacus. The iliacus muscle is divided 1 cm below and medial to this line, and the
remaining muscle is swept from the surface of the iliac bone by blunt finger dissection to preserve the periosteal
supply.
Lower Lateral Dissection
Because the deep circumflex iliac artery supplies the ilium from its medial side, in the lower lateral dissection, the
muscles attached to its lateral aspect can be safely separated from the bone. It is useful to retain some of the
attachments to this side of the bone for use in mandibular reconstruction. A segment
of tensor fasciae latae can be left on the outer lip of the iliac crest to reattach the masseter muscle. Similarly, the
tendon of the rectus femoris is preserved at the anterior inferior iliac spine for reconstruction of the capsule of the
temporomandibular joint.
FIGURE 208.6 Case 1. A: A recurrent squamous cell carcinoma with fistula onto the neck. Note the margins of
the soft-tissue excision. B: Resection of the tumor. (From Taylor, ref. 12, with permission.)
The upper and lower lateral parts of this dissection are then joined beyond the tuberosity of the crest. The
remaining muscle attachments are separated from the bone as far posteriorly as the posterior superior iliac spine
if this length of bone graft is required. The terminal branch of the deep circumflex iliac artery is thereby preserved
in this part of the dissection. Finally, the inguinal ligament is detached from the anterior superior iliac spine, and
the iliacus muscle is divided as it passes under the vascular pedicle. In so doing, the lateral cutaneous nerve of
the thigh will be encountered. In some cases, its continuity can be retained; in others, it may have to be divided
and repaired.
Bone Section
Careful preoperative planning and the use of bone models provide an accurate assessment of the required
length and shape of the bone graft. The ilium is sectioned with an oscillating or reciprocating saw. The bone is
eased medially to prevent tension on the vascular pedicle. Further contouring and any osteotomies are
performed while the graft is in situ. This shortens the ischemia time and permits circulatory readjustment in the
flap before transfer.

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FIGURE 208.7 Case 1. Pattern of the soft-tissue and bone requirements transferred to the ipsilateral hip. The
skin flap measured 28 × 15 cm, and the bone graft, which measured 21 × 7 cm, included the entire iliac crest.
Because the blood supply to the bone enters the medial cortex, it is possible to remove excess bone or, indeed,
the entire outer cortex if desired. Osteotomies may be performed to adjust the curvature of the bone. The
integrity of the medial periosteum is preserved for distal graft perfusion, together with the attachments of the
transversus and iliacus muscle to the inner lip of the iliac crest.
Removal of the wing of the ilium creates a breach in the lateral abdominal wall that requires careful closure. It is
essential to repair the transversus muscle to the iliacus or the remaining iliac bone. Because the iliacus muscle is
tenuous posteriorly, we have found it useful to drill a number of holes in the cut edge of the ilium to reattach the
transversus muscle. The remaining part of the closure involves suture of the glutei and the tensor fasciae latae
to the internal and external oblique muscles. A Tanner slide procedure may be useful if there is insufficient laxity
in the external oblique.
FIGURE 208.8 A-C: Case 1. The result at 3 years. A bone scan and bone biopsies taken on either side of the
osteotomy at day 5 confirmed viability of the entire graft. At 6 weeks, the external fixation was removed, at which
stage there was clinical union of the bone. The skin flap was thinned on two occasions, at 3 and 5 months.

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FIGURE 208.9 Case 1. The donor site. Note the hip contour after removing the entire iliac crest and a large skin
flap. (From Taylor, ref. 10, with permission.)
FIGURE 208.10 Case 2. Right hemifacial microsomia in a 13-year-old with deformity of the right ear and partial
right facial palsy. The right ramus and a portion of the body of the mandible were absent, the ear and right
maxilla were underdeveloped, and the soft tissues of the right side of the face were deficient. Two previous
attempts at reconstruction—a silicone block spacer at 2 years of age and a conventional costochondral graft at
11 years of age—had been extruded owing to infection. Electrical studies showed that the right facial nerve was
absent and what function the patient had was innervated from the left side. (From Taylor, ref. 10, with
permission.)

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FIGURE 208.11 Case 2. Diagram of the procedure. Left: Sagittal osteotomy of the left side of the mandible to
centralize the chin. Center: Graft split from the hip with an additional flap of hemiapophysis to cap the new head
of the mandible, A. This was done to retain normal hip development and to provide a possible growth center for
the jaw. Right: The graft in position with anastomosis of the deep circumflex iliac vessels to the facial artery and
common facial vein. The skin flap (dotted lines), shaved of epithelium, reconstitutes soft-tissue contour. (From
Taylor, Daniel, ref. 11, with permission.)
FIGURE 208.12 Case 2. A: Pattern of the soft-tissue and bone requirements. B: The composite graft isolated on
the deep circumflex iliac pedicle. A portion of the skin flap has been shaved of epithelium. A small portion of the
skin flap was left intact to monitor the vascularity postoperatively. C,D: Flap of apophysial cartilage turned to cap
the new head of the mandible. (From Taylor, Daniel, ref. 11, with permission.)

FIGURE 208.13 A,B: Case 2. At 2 years, there is good correction of facial symmetry. No attempt has been made
to correct the facial palsy. (From Taylor, Daniel, ref. 11, with permission.)
CLINICAL RESULTS
The main disadvantage of this graft is its bulk, especially in obese or muscular patients; however, the skin
and subcutaneous tissues can be omitted and the attached muscle sealed with a split-thickness skin graft.
Alternatively, the skin flap may be thinned at a later stage.
SUMMARY
The deep circumflex groin skin and iliac crest flap provides both skin cover and lining, as well as
vascularized bone, for mandibular reconstruction.
FIGURE 208.14 Case 2. The hip contour and function are normal. (From Taylor, ref. 10, with permission.)
References
1. Taylor GI, Townsend P, Corlett RJ. Superiority of the deep circumflex iliac vessels as the supply for free
groin flaps: experimental work. Plast Reconstr Surg 1979;64:595.
2. Taylor GI, Townsend P, Corlett RJ. Superiority of the deep circumflex iliac vessels as the supply for free

groin flaps: clinical work. Plast Reconstr Surg 1979;64:745.
3. Manchester WM. Some technical improvements in the reconstruction of the mandible and
temporomandibular joint. Plast Reconstr Surg 1972;50:249.
4. Merritt WH, Acharya G, Johnson ML. Complications in 45 island pectoralis major myocutaneous flaps for
head and neck cancer reconstruction: a 13-month follow-up. Presented at the Annual Meeting of the
American Society of Plastic and Reconstructive Surgeons, New York, October 23, 1981.
5. Baek S, Lawson W, Biller HF. An analysis of 133 pectoralis major myocutaneous flaps. Plast Reconstr
Surg 1982;69:460.
6. Mehrhof A, Rosenstock A, Neifeld JP, et al. The pectoralis major myocutaneous flap in head and neck
reconstruction: an analysis of complications. Am J Surg 1983;146:478.
7. Reid C, Taylor GI. The vascular territory of the acromiothoracic axis. Br J Plast Surg 1984;37:194.
8. Serafin D, Buncke HJ. Vascularized rib periosteal transplantation. In: Serafin D, Buncke HJ, eds.
Microsurgical composite tissue transplantation. St. Louis: Mosby, 1979. Chap. 31.
9. Soutar DS, Scheker LR, Tanner NSB, McGregor IA. The radial forearm flap: a versatile method for
intraoral reconstruction. Br J Plast Surg 1983;36:1.
10. Taylor GI. The current status of free vascularized bone grafts. Clin Plast Surg 1983;10:185.
11. Taylor GI, Daniel RK. Aesthetic aspects of microsurgery. Clin Plast Surg 1981;8:333.
12. Taylor GI. Reconstruction of the mandible with free composite iliac bone grafts. Ann Plast Surg
1982;9:361.

Chapter 209
Microvascular Free Transfer of The Medial Wall of The Iliac Crest
on The Deep Circumflex Iliac Artery for Mandibular
Reconstruction
H. R. STERMAN
B. STRAUCH
EDITORIAL COMMENT
Use of the medial wall eliminates much of the postoperative discomfort of the patient. Although the
osteotomized free fibular flap is more frequently used for mandibular reconstruction, especially when
additional lining or skin is needed, the iliac-crest free flap remains an excellent technique when only bone is
required.
The deep circumflex iliac artery (DCIA) osseous or osteocutaneous free flap is a technique for oromandibular
reconstruction that maximizes function as well as form and maintains the quality of life for patients who may be
cured or may only have a few months to live (1, 2, 3, 4, 5, 6, 7, 8, 9, 10). A modification of the original flap that
uses only the medial wall of the iliac crest has contributed a major advance, now allowing the bone flap to fill the
defect precisely, thus refining its bony component and reducing morbidity.
INDICATIONS
The original DCIA flap was used when any defect of the mandible existed, from the condyle to the
parasymphysis. Even defects that crossed the mentum could be reconstructed, and grafts up to 16 cm
could be harvested along the crest. For extended defects that cross the mentum, a free osteotomized fibula
is a better choice.
The DCIA osseous/osteocutaneous flap is better suited for reconstruction of the ramus, angle, and body of
the mandible because of its natural curvature. When an osteocutaneous flap is involved, defects of the
mucosa and extraoral skin can be replaced by using a large skin paddle. If the soft-tissue defect is relatively
large, an accessory flap for mucosal or skin coverage may be required. The medial-wall DCIA free flap can
be taken with bone alone or as a myooseous or even osteocutaneous flap, thus providing for oral lining and
bone for the reconstruction, or even provision of external skin. The medial-wall flap has become the flap of
choice for segmental mandibular defects.
Advantages of using the medial wall include significantly less donor-site morbidity, such as pain, hernia,
deformity, and gait disturbance. The medial cortex is thinner and provides a flap that is less bulky, provides
good contour, and is more cosmetically acceptable. Variations include the use of the internal iliac muscle for
soft-tissue coverage (10), allowing the muscle to be rotated through any arc, for coverage of any defect,
and provision of thin, pliable tissue. This flap allows soft-tissue coverage with reconstruction of almost any
mandibular defect except defects that cross the mentum. The thickness of the iliac-crest flap allows
placement of osseointegrated implants into the free vascularized bone graft.
ANATOMY

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The medial-wall DCIA osseous or osteocutaneous flap is based on the DCIA that originates from the
posterolateral aspect of the external iliac artery just above the inguinal ligament. It runs parallel to the ligament in
the fascial sheath formed by the junction between the transversalis and iliac fascia. A large ascending branch is
given off 1 cm medial to the anterior iliac spine; it runs superiorly under the internal oblique muscle. The DCIA
passes along the lip of the iliac crest and ends 6 to 9 cm past the anterosuperior iliac spine. While traveling
along the iliac crest, perforators are given off to the muscle and skin.
The pedicle of the DCIA is approximately 5 to 6 cm, and the artery averages 2.0 cm in diameter. The
accompanying vein is 3.0 cm in diameter. The ascending branch originates in 65% of cases within 1 cm of the
anterior superior iliac spine. In 15% of cases, the ascending branch originates 2 to 4 cm from the anterior
superior iliac spine (ASIS); in another 20% of cases, there is no single vessel but rather two or three small
vessels near the ASIS.
FLAP DESIGN AND DIMENSIONS
The iliac crest has a natural curvature that is well suited for mandibular reconstruction. If full-thickness bone is to
be taken alone, the usable amount of bone is generally about 14 cm. When an osteocutaneous flap is needed, a
skin flap of 20 × 16 cm can be raised along with the bone. The skin flap is taken from the upper border of the
anterior part of the iliac crest. The medial-wall DCIA free flap can be harvested with up to 12 cm of bone for
defects of the mandible and, because of the introduction of the split cortex, donor-site morbidity is decreased.
OPERATIVE TECHNIQUE
The patient is placed in the supine position with a sandbag under the opposite buttock.
Medial-Wall DCIA Osseous Flap
An incision is made along the upper border of the inguinal ligament and iliac crest, approximately the length of
the anticipated bone graft. The incision is carried down to the level of the external oblique aponeurosis, and it is
split parallel with and 1 cm above the upper edge of the inguinal ligament at its midpoint up to the ASIS. The
posterior wall of the inguinal ligament is exposed by retracting the spermatic cord or round ligament medially and
upward. At this point, the external iliac artery can be palpated through the internal oblique muscle.
The external iliac artery is dissected out, and the DCIA will be found on its posterior lateral aspect. (The
advantage of this medial dissection is that if there are any vascular anomalies, they can be detected early.) The
DCIA is dissected out by incising the sheath of the transversalis fascia and dissecting the internal oblique and
transversus muscles from the inguinal ligament. As the dissection moves laterally, identifying the ascending
branch and tracing it downward will make dissection of the vascular pedicle easier and safer. The ascending
branch will be located approximately 1 cm above and medial to the ASIS, between the internal oblique and the
transversus muscles. In this area, the lateral femoral cutaneous nerve will be found. If the nerve runs beneath the
vessels, its continuity can be preserved; however, if found superficial to the vessels, it must be divided and
repaired.
The DCIA is followed along its path as it curves around the iliac crest. The incision is extended as well, and the
abdominal wall musculature is detached from the crest. The ascending branch is divided and ligated. The DCIA
is traced posteriorly by dividing the transversalis fascia and separating the extraperitoneal fat from the iliacus
while maintaining the vascular bundle attachments to the iliacus muscle.
The iliacus fascia and muscle are divided along the length of the bone desired, at a minimum of one finger
breadth below the DCIA, and the medial or inner surface of the ilium is exposed. No more than 2 cm of crest is
needed for the reconstruction. The distal end of the DCIA then is divided and ligated. Although the full thickness

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of the iliac crest can be harvested, it is too bulky; the medial (inner) lip can be harvested, basing it on the DCIA,
thereby producing a less bulky flap and less deformity at the donor site.
The lateral edge of the iliac crest is osteotomized with either an oscillating saw or a Midas Rex high-speed drill.
The osteotomy should skew to the lateral table to maintain sufficient bone on the medial wing. The osteotomies
are carried down the medial wall anteriorly and posteriorly, and an inferior cut is made as well. As the crest gets
thinner when moving inferiorly, osteotomes should be used to separate the leaves of the crest.
The pedicle then is divided after the recipient site has been prepared. Accurate and careful closure of the donor
site is mandatory; otherwise, herniation of the peritoneal contents will occur. The iliacus muscle and fascia
should be sutured to the transversalis fascia and muscle. The external and internal oblique muscles should be
sutured to the gluteal and TFL muscles. If the inguinal canal and ligament have been divided, repair will be
necessary (Fig. 209.1).
Iliac Osteocutaneous Flap (Based on the DCIA)
The largest skin paddle that can be raised for this flap has been reported to be 20 × 16 cm. The axial line of the
flap is placed along the anterior part of the iliac crest. A rest is placed beneath the hip on the side that is to be
harvested. The incision is made along the upper border of the iliac crest down through the subcutaneous tissue.
The external aponeurosis is exposed and split parallel to and 1 cm above the inguinal ligament, from the midpoint
of the ligament to the anterior superior iliac spine. The round ligament and spermatic cord are retracted medially
and superiorly, exposing the posterior wall of the inguinal canal (which consists of the transversalis fascia at that
point) and the external iliac artery.
Once the external iliac artery is exposed, the DCIA is identified coming off posterolateral to the external iliac
artery. The DCIA travels laterally in the sheath of the transversalis fascia beneath the internal oblique and
transversus muscles. The transversalis fascia is found by detaching the internal oblique and transversus
muscles from the inguinal ligament. As the dissection progresses laterally, the ascending branch can be found 1
cm superiorly and medially to the ASIS, between the internal oblique and transversus muscles. By tracing the
ASIS inferiorly, identification of the vascular pedicle of the DCIA flap is found. The lateral femoral cutaneous
nerve is also found in this area. If it is located beneath the artery, it can be preserved; if it is found superficial to
the vessels, it must be divided and repaired.
Once the pedicle is dissected free, the anterior border of the flap is incised through the skin and subcutaneous
fat. The transversus abdominis, external oblique, and internal oblique muscles are divided, leaving a 2- to 3-cm
cuff of muscle with the skin flap attached to the bone. The transversalis fascia is divided, exposing the DCIA as it
travels in the line of fusion between the iliacus and the transversalis fascia. Then the posterior skin incision is
made and carried down through the subcutaneous fat to the tensor fasciae latae and gluteal muscles. The skin
flap is dissected from the iliac crest and the edge is exposed. The inner table then is harvested by osteotomizing
along the crest and down through the medullary bone. The length of the flap is determined by making
osteotomies perpendicular to the crest.
CLINICAL RESULTS
Use of the hemiiliac crest for mandibular-body reconstruction allows for the restoration of continuity, with
good contour, and a high degree of long-term reliability.

FIGURE 209.1 A: Patient with infected osteoradionecrosis of the mandible, initially treated with
debridement and external fixation. B: Reconstruction accomplished at a later stage, with harvesting of the
medial wall of the iliac crest on the deep circumflex iliac artery DCIA. C: Representation of an A-V fistula
created with the saphenous vein between the external carotid artery and jugular vein at the time of
reconstruction. D: Illustration of the hemiiliac crest, inset and secured, with subsequent vascular repair
completed to the divided A-V fistula. E: Postoperative appearance at 1 year. The patient is back to golfing;
dental restoration carried out with osseointegrated implants.
SUMMARY
The DCIA is a hardy, reliable source of vascularized bone because of its consistent vascular anatomy, long
pedicle, and satisfactory vessel diameter. The flap provides good-quality bone in quantities sufficient for
reconstructions extending up to hemimandibular defects. By taking only the medial wall, flap thickness is
reduced, the reconstruction is more aesthetic, and donor-site morbidity is diminished. At many centers, the
DCIA medial cortex flap has become the standard for mandibular reconstruction.
References
1. Boyd JB. Mandibular reconstruction in the young adult using free vascularized iliac crest. Microsurgery
1988;9:141.

2. Boyd JB. The place of the iliac crest in vascularized oromandibular reconstruction. Microsurgery
1994;15:250.
3. Daniel R. Mandibular reconstruction with free tissue transfers. Ann Plast Surg 1978;1:346.
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experience. Plast Reconstr Surg 1988;82:792.
5. Jewer DD, Boyd JB, Manktelow RT, et al. Orofacial and mandibular reconstruction with the iliac crest free
flap: a review of 60 cases and a new method of classification. Plast Reconstr Surg 1989;84:391.
6. Moscoso JF, Urken ML. The iliac crest composite flap for oromandibular reconstruction. Otolaryngol Clin
North Am 1994;27:1097.
7. Strauch B, Yu HL. Atlas of microvascular surgery: anatomy and operative approaches. New York:
Thieme, 1994;142-155.
8. Shenaq SM, Klebuc MJ. The iliac crest microsurgical free flap in mandibular reconstruction. Clin Plast
Surg 1994;21:37.
9. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free
groin flaps. Plast Reconstr Surg 1979;64:595.
10. Urken ML, Vicker C, Weinberg H, et al. The internal oblique-iliac crest osseocutaneous microvascular
free flap in head and neck reconstruction. J Reconstr Microsurg 1989;5:203.